HomeMy WebLinkAbout02-0419
MARY C. LEWIS, REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
PETITION FOR GRANT OF LETTERS
Estate of LEROY S. JACOBS
No.21
02
419
also known as
, Deceased
Social Security No. 057-10-4212
SHIRLEY ANN RUSSELL AND LEROY J. JACOBS
Petitioner(s), who is/are 18 years of age or older, apply)ies) for:
(COMPLETE "A" OR "B" BELOW:)
GJ
A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut
Decedent, dated 7/24/01 and codicil(s) dated N/A
named in the Last Will of the
State relevant circumstances, e.g., renunciation, death of executor, etc
Except as follows, Decedent did not marry, was not divorced and did not have a child born or adopted after execution of the documents offered
for probate; was not the victim of a killing and was never adjudicated incapacitated:
o
B. Grant of Letters of Administration
(c.t.a., d.b.n.c.t.a.: pendente lite, durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse
(if any) and heirs:
I
Name
Relationship
Residence
I
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his/her last family or principal
residence at MESSIAH VILLAGE 100 MT. ALLEN DR., UPPER ALLEN TWP., MECHANICSBURG, PA 17055
(list street, number and municipality)
Decedent, then 86 years of age, died APRIL 22 ,2002 ,at MESSIAH VILLAGE, MECHANICSBURG, PA
(Location)
Decedent at death owned property with estimated values as follows:
(if domiciled in PA All personal property ......................................... $
(if not domiciled in PA Personal property in Pennsylvania .................... $
(if not domiciled in PA Personal property in County.............................. $
Value of real estate in Pennsylvania ........................................................................................ $
Total.............. ............... ................................. ........................ .......................... ..... $
170,000.00
170,000.00
Real Estate situated as follows: NONE
Wherefore, Petitioner(s) respectfully request(s) the probate of the Last Will and Codicil(s) presented with this Petition and the grant of letters in
the appropriate form to the undersigned:
Typed or printed name and residence
SHIRLEY ANN RUSSELL
1426 N. 6TH AVENUE AL TOONA PA 16601
LEROY J. JACOBS
725 OBERLIN STREET STEEL TON PA 17113
RW-1
/~-o9- /3
Oath of Personal Representative
Commonwealth of Pennsylvania
County of CUMBERLAND
The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true
and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the
Decedent, Petitioner(s) will well and truly administer the esta e c<:.ording to law.
Sworn to and affirmed and subscribed
SHIR E ANN R ELL
before me this 2.iiTH dayo! /~ ~
APRIL. 2002. /7 ~ ~_
~ ~ ) LEROYJ
7u~I(/ f~d;2<'~~
DECREE OF REGISTER
Estate of LEROY S. JACOBS
also known as
Deceased
No.21
02 419
Date of Death:
04-22-2002
Social Security No: 057-10-4212
AND NOW, APRIL 25. 2002
reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters U Testamentary 0 of Administration
are hereby granted to
I in consideration of the Petition on the
((c.t.a., d.b.n.c.t.; pendente lite; durante absentia; durante minoriate)
SHIRLEY ANN RUSSELL AND LEROY .J .JACOBS
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in the above estate and that the instrument(s), if any, dated .JULY 24th ::>001
described in the Petition be admitted to probate and filed of record as the Last Will of Decedent.
FEES
Letters ....................................
Short Certificates(s) ...............
Renunciation......................... .
Extra Pages (
) ...............
I.T.R.......................................
JCP Fee .................................
Inventory............................... .
Other..................................... .
TOTAL .............................$
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$
235.00
',)
~74 l;fuvJfdA/ /,l)/uy
glster of Wills 0',
$
$
$
$
$
$
$
$
18.00
6.00
,3~4 ~
-' / Signature
5.00
Attorney: GERALD J. BRINSER
I.D. No: 09655
Address: 6 E. MAIN STREET, P.O. BOX 323
PALMYRA PA 17078
Telephone: (717)838-6348
DATE FILED: 4/25/02
264.00
T
WILL
OF
LEROY S. JACOBS
I, LEROY S. JACOBS, currently of Upper Allen Township, Cumberland County,
Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any and all
prior Wills and Codicils made by me.
I. I direct that all my just debts and funeral expenses be paid from the assets of my
estate as soon as practicable after my demise.
II. I direct that all estate and inheritance taxes that may be assessed in consequence of
my death, shall be paid out of the principal of my general estate to the same effect as if said
taxes were expenses of administration and all property includable in my taxable estate
whether or not passing under this Will shall be free and clear thereof.
III. All the rest, residue and remainder of my estate, of whatever nature and wherever
situate, including property over which I hold a power of appointment, I devise and bequeath
as follows:
A. Five Thousand Dollars ($5,000) unto each of my daughter's
children, namely, Sharon, David and Scott.
B.
Angela.
Fifteen Thousand Dollars (15,000) unto my son's daughter,
C. Five Thousand Dollars ($5,000) unto each of my great-
grandchildren who survive me.
D. All the rest, residue and remainder of my estate I devise and
bequeath equally unto my children, Shirley and Leroy. If either child
predeceases me, his or her share shall pass unto his or her issue per stirpes.
If said child leaves no issue, said share shall lapse and be added to the share
passing to my other child or his or her issue per stirpes.
~~
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IV. I appoint my daughter, Shirley Ann Russell, and my son, Leroy J. Jacobs,
Executors, or the survivor of them as sole Executor, of this my Will.
V. I direct that no bond be required of my fiduciaries for the faithful performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I, LEROY S. JACOBS, herewith set my hand to this
my Last Will, typewritten on two (2) sheets of paper including the attestation clause and
signatures of witnesses, this .:RI{o#, day of ..:r (./ L Y , 2001.
GT~ /1- ~MSEAL)
LER S. JAC~
Signed by LEROY S. JACOBS, by him declared to be his Will in our presence, who
have hereunto subscribed our names as witnesses in his presence and at his request, this
~Vp,. ~ of Ic..J Lj , 20~O1.
ft~~ ~ residingat ~ ~.ft
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residing at
~.... -,dl~ po-.-
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COMMONWEAL TH OF PENNSYLVANIA
COUNTY OF J L.\lJG1N t\A"",l:H'I~\Q^-~
WE, LEROY S. JACOBS, GERALD J. BRINSER and \5ac.-JYLC- lSf1:)Ou.:ls~
the testator and the witnesses, respectively, whose names are signed to the attached or
foregoing instrument, being first duly affirmed, do hereby declare to the undersigned
authority that the testator signed and executed the instrument as his Last Will and that he
signed willingly (or willingly directed another to sign for him), and that he executed it as his
free and voluntary act for the purposes therein expressed, and that each of the witnesses, in
the presence and hearing of the testator, signed the Will as witnesses and that to the best of
our knowledge the testator was at that time eighteen years of age or older, of sound mind and
under no constraint or undue influence.
~~~
WITNESS
Subscribed, sworn or affirmed and acknowledged before me by LEROY S. JACOBS, the
testator, GERALD J. BRINSER and ~~"'-J'ICJ.E B~(}...>...)s IC..r , witnesses, this
~tjt:i day of ~ u..ll ,2001.
o >>1. ~ (SEAL)
Notary Public
Notarial Seal
Vicky M. MlcuIlta. Notary Public
Upper Allen Twp.. Cumberland County
My Commission Expires Dec. 31, 2001
Member, PennsylVania Association 01 Notaries
-3-
STATUS REPORT UNDER RULE 6.12
{\ .;
VJ10-
Name of Decedent: LEROY S. JACOBS
Date of Death: 4/22/02
Will No. 2002-00419
Admin. No.
Pursuant to Rule 6. 12 of the Supreme Court Orphans I
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1 . State whether administration of the estate is complete:
Yes X No
2 . If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3 . If the answer to No. 1 is Yes, state the following:
a.
account with the Court?
Did the personal representative file a final
Yes No X
b . The separate Orphans' Court No. (if any) for
the personal representative I s account is:
c . Did the personal representative state an
account informally to the parties in interest ? Yes X No
d . Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Clerk of the Orphans' Court and may be attached to this report.
Date: 12/24/02
_~1~1W&~
Signature
GERALD J. BRINSER
Name (Please type or print)
6 E. MAIN STREET, P.O. BOX 323
PALMYRA PA 17078
Address
( 717 ) 838- 6348
Tel. No .
Capacity :
Personal Representative
X
Counsel for personal
representative
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BRINSER GERALD J
6 E MAIN STREET,2ND FLOOR
POBOX 323
PALMYRA, PA 17078
-------- fold
ESTATE INFORMATION: SSN: 057-10-4212
FILE NUMBER: 2102-0419
DECEDENT NAME: JACOBS LEROY S
DATE OF PAYMENT: 10/23/2002
POSTMARK DATE: 10/22/2002
COUNTY: CUMBERLAND
DATE OF DEATH: 04/22/2002
NO. CD 001765
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $655.89
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I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$655.89
MARY C. LEWIS
REGISTER OF WILLS
j
...
LAW OFFICES
BRINSER, WAGNER & ZIMMERMAN
6 EAST MAIN STREET - SECOND FLOOR
(EAST MAIN & SOUTH RAILROAD STREETS)
P. O. BOX 323
PALMYRA, PA 17078
PHONE: (717) 838-6348
FAX: (717) 838-6912
MECHANICS BURG OFFICE
MESSIAH VILLAGE
100 MT. ALLEN DRIVE
MECHANICS BURG, PA 17055
PHONE/FAX (717) 795-1737
GERALD J. BRINSER
KEITH D. WAGNER
JOHN M. ZIMMERMAN
October 18, 2002
Mary C. Lewis, Register of Wills
Cumberland Count Court House
S. Hanover Street
Carlisle, P A 17013
In Re:
Leroy S. Jacobs Estate
File No. 21-02-0419
Dear Ms. Lewis:
Enclosed you will find two (2) copies of a Supplemental Inheritance Tax Return for
the above-captioned estate. Also enclosed are two (2) checks: one in the amount of $15 .00
for the filing fee and one in the amount of$655.89 for the tax due.
If you have any questions, please feel free to give me a call.
Thank you.
Very truly yours,
BRINSER, WAGNER:&: ZIMMERMAN
;dwH~.~,~
Gerald J. Brinser
GJB/wlc
Enclosures
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BRINSER GERALD J
6 E MAIN STREET,2ND FLOOR
POBOX 323
PALMYRA, PA 17078
_n__n_ fold
ESTATE INFORMATION: SSN: 057-10-4212
FILE NUMBER: 2102-0419
DECEDENT NAME: JACOBS LEROY S
DATE OF PAYMENT: 07/15/2002
POSTMARK DATE: 07/12/2002
COUNTY: CUMBERLAND
DATE OF DEATH: 04/22/2002
NO. CD 001408
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $7,266.63
I
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I
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I
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TOTAL AMOUNT PAID:
REMARKS: LEROY J JACOBS & SHIRLEY A
RUSSELL C/O A TTY NO CHECK #
SEAL
INITIALS: CW
RECEIVED BY:
REGISTER OF WILLS
$7,266.63
MARY C. LEWIS
REGISTER OF WILLS
.'
MARY C. LEWIS, REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
c.
INVENTORY
Estate of LEROY S. JACOBS
No. 21
02
0419
, Deceased
Date of Death 04/22/2002
Social Security No. 057-10-4212
also known as
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no
real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. IMle
verify that the statements made in this inventory are true and correct. IMle understand that false statements herein made are subject to the
penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Name of
Attorney: GERALD J. BRINSER
I.D. No.: 09655
Address: 6 E. MAIN STREET, P.O. BOX 323
PALMYRA
Dated JULY 9, 2002
PA 17078
Telephone: (717)838-6348
Description
Value
Stocks & Bonds
(607) SHARES SCUDDER INVESTMENTS
4,698.47
Cash, Bank Deposits, & Misc. Personal Property
WAYPOINT BANK - C.D. #168236356
(INCLUDES ACCRUED INTEREST OF $79.11)
25,079.11
WAYPOINT BANK - C.D. #1865307130
(INCLUDES ACCRUED INTEREST OF $39.58
"p' ~
j :_)
10,039.58
WAYPOINT BANK - C.D. #1865307141
(INCLUDES ACCRUED INTEREST OF $18.4,1- ,. ..>' ,~'. t
5,018.41
ZO.
Total
(Attach Additional Sheets if necessary)
176,865.17
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative,
include the value of each item, but such figures should not be extended into the total of the Inventory.
RW-4
Continuation of Inventory
LEROY S. JACOBS
21
02
0419
PaQe 1
Description of Inventory
Description
WAYPOINT BANK - C.D. #1868222167
(INCLUDES ACCRUED INTEREST OF $40.84
Value
10,340.83
WAYPOINT BANK - C.D. #1868222202
(INCLUDES ACCRUED INTEREST OF $63.17
18,063.17
PNC BANK - CHECKING ACCOUNT #5070081566
(INCLUDES ACCRUED INTEREST OF $.25)
6,795.45
PNC BANK - SAVINGS ACCOUNT #5001901954
(INCLUDES ACCRUED INTEREST OF $5.23)
31,902.88
FIRST UNION NATIONAL BANK - C.D.#247412096055702
(INCLUDES ACCRUED INTEREST OF $42.82)
27,042.82
FIRST UNION NATIONAL BANK - C.D. #247412097048963
(INCLUDES ACCRUED INTEREST OF $30.73)
10,030.73
FIRST UNION NATIONAL BANK - C.D. #247412097049013
(INCLUDES ACCRUED INTEREST OF $75.68)
17,575.68
FIRST UNION NATIONAL BANK - C.D. #247412097049102
(INCLUDES ACCRUED INTEREST OF $11.19)
10,011.19
BLUE CROSS/BLUE SHIELD - REIMBURSEMENTS
266.85
Subtotal
$
132,029.60
176,865.17
Grand Total $
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. COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT,280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECEDENrS NAME (LAST, FIRST, AND MiDDlE INITIAL)
JACOBS LEROY S.
DATE OF DEATH (MM-OI).Yea)
DATE OF BIRTH (MM-DO-Year)
OFFICIAl USE ONlY G
n~ '7 -~f - 1 3
FILE NUMBER
2 1 -0 2 0 4 1 9
""CcUffi'""Ccii'i"" -YEAR- --mmeR--
SOCIAL SECURITY NUMBER
o 57- 1 0 - 4 2 1 2
THIS RETURN MUST BE FILED IN DUPlICATE WITH THE
REGISTER OF WILLS
SOCIAL SECU~TY NUMBER
o 3. Remainder Retum l_ofdeathpiorb12-13-82)
D 5, Federal Eslate Tax Retum Required
Q.. 8, Total Number of Safe Deposit Boxes
D 11,ElectiontotaxunderSec.9113(A)_""OJ
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
GERALD J. BRINSER ESQUIRE 6 E. MAIN STREET
FIRM NAME (ff AWicabIe)
BRINSER WAGNER & ZIMMERMAN P.O, BOX 323
TELEPHONE NUMBER
717838-6348 PALMYRA PA 17078
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04/22/2002 10/19/1915
pF APPLICABLE) SURVIVING SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITIAL)
N/A
00 Uxiginel Return
D 4. Limited Eslate
00 6. DecedenlDiedTeslate 1__oIW.)
D 9. Litigation Proceeds Received
D 2. Supplemenlal Return
o 4a.FuturelnlerestCompromise(daI&ofdeathafter12-12--tl2j
D 7, Decedent Maintained a L~ing Trust_""oIT""'i
o 10. Spousal Poverty Cred~ [dliBofdeath between 12-31-91 and 1-1-95)
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1. Real Eslale (Schedule A)
2, SIocI<s and Bonds (Schedule B)
3, Closely Held Corporation, Partnership or Sole-Proprietor>hip
4, Mortgages & Noles Rece~able (Schedule D)
5, Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. JoinUy OWned Property (Schedule F) (6)
D Saparate Billing Requested
(1)
(2)
(3)
(4)
(5)
7.lntef-Vivos Transfer> & MOcellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Groll_ (tolal Lines 1-7)
9, Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage L~bililies, & Liens (Schedule I) (10)
11. Total Deducllonl (toIal Lines9& 10)
12, Not Vllue of EIlala (Line 8 minus Line 11)
13, Charilable and Govemmenlal BequestslSec 9113 Trusts for which an election to tax has not been
made (Schedule J)
(8)
14. NotVllu. Subject!o Tax (line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15, Amounl of Line 14laxable at the spousal tax
rate, or transfer> under See. 9116 (aX1.2)
0.00 X
169,979.59 X
0.00 X .12
.OL(15)
,04.5 (16)
16. Amount of Line 14 taxable atlineal rale
17, AmounlofLine 14 taxable alsibling rate
18, Amounl of Line 14 taxable al collateral rale
(17)
0.00 X ,15 (18)
(19)
19. Tax Due
20 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
OFFICIAl USE ONLY
4;698,471 ":'
'--
,
172,166.701:
,
.':::>.
176.865,17
4,434,00
2,451.58
(11)
(12)
(13)
6.885,58
169,979.59
(14)
169.979,59
7,649.08
7,649,08
T
Decedent's ComDlete Address: .
STREET ADDRESS
MESSIAH VILLAGE
100 MT. ALLEN DRIVE
CITY I STATE I ZIP
MECHANICSBURG PA 17055
~
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Disoount
(1)
7,649.08
382.45
Total Credits (A + B +C)
(2)
382.45
3. InteresVPenalty ij applicable
D. Interest
E. Penalty
Total /nteresVPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the differenoe. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Une 2, enter the differenoe. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN .X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. relain the use or income of the property transferred; ........................................................................... 0 00
b. retain the right to designate who shail use the property transferred or its income: ........................................ 0 00
c. relain a reversionary interest; or ...................................................................................................... 0 00
d. receive the promise forlile of either payments, benefits or caTe? ............................................................. 0 00
2. If death oocurred aner December 12, 1982, did decedent transfer property within one year of dealh
without receiving adequate consideration?..............."............................................................................. 0 00
3. Did decedent own an 'in trust for' or payable upon death bank accounl or security at his or her dealh? ................. 0 00
4. Did decedent own an Individual Retirement Aocount, annuity, or other non-probate property which
contains a beneficiary designation? ............................................................. .......................................... 0 00
7,266.63
7,266.63
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
PA 17113
DATE
o~
PA 17078
For dates of death on or aner July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
(72 P.S. ~9116 (a)(1.1) (i)).
For dates of death on or aner January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% (72 P.S. ~9116 (a) (1.1)(ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is lhe only beneficiary.
For dates of death on or aner July 1, 2000:
The tax rate imposed on Ihe net value of transfers from a deceased c:I1ild twenty",ne years of age or younger at dealh 10 or for the use of a natural parent, an adoptive parent,
or a slepparent of the child is 0% [72 P.S. ~9116(a)(1.2)J.
The lax rata imposed on the nel value of transfers 10 or for Ihe use of the decedent's lineal beneficianes is 4.5%, exoept as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or for Ihe use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)J. A sibiing is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
"'
REV-"'''.'''''_~~
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COMMONWEALTH Of PENNSYLVANIA
INHERITANCE TAX RETURN
I
SCHEDULE B
STOCKS & BONDS
ESTATE OF
JACOBS LEROY S
All property jolnUy.....od with right of survivorship mllll be disclosed on Schedule F,
ITEM
NUMBER
1.
FILE NUMBER
21 02
0419
DESCRIPTION
(607) SHARES SCUDDER INVESTMENTS
VALUE AT DATE
OF DEATH
4,698.47
TOTAL (Also enter on line 2, Recapitulation) $
(ff more space is needed, insert additional sheets of the same size)
4 698.47
,
REY.'''EX.i1.9n~_
p '~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21 02
ESTATE OF
JACOBS LEROY S
0419
Include lt1e proceeds of iligalion and lt1e dale lt1e proceeds were receNed by It1e estate. All property jolnUy.....ed with 111. right of SUrvivOR hip must be disclosed on Schedule F,
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9,
10.
11.
12.
DESCRIPTION
WAYPOINT BANK - CERTIFICATE OF DEPOSIT #168236356
(INCLUDES ACCRUED INTEREST OF $79.11)
WAYPOINT BANK - CERTIFICATE OF DEPOSIT #1865307130
(INCLUDES ACCRUED INTEREST OF $39.58
WAYPOINT BANK - CERTIFICATE OF DEPOSIT #1865307141
(INCLUDES ACCRUED INTEREST OF $18.41
WAYPOINT BANK - CERTIFICATE OF DEPOSIT #1868222167
(INCLUDES ACCRUED INTEREST OF $40.84
WAYPOINT BANK - CERTIFICATE OF DEPOSIT #1868222202
(INCLUDES ACCRUED INTEREST OF $63.17
PNC BANK - CHECKING ACCOUNT #5070081566
(INCLUDES ACCRUED INTEREST OF $.25)
PNC BANK - SAVINGS ACCOUNT #5001901954
(INCLUDES ACCRUED INTEREST OF $5.23)
FIRST UNION NATIONAL BANK - CERTIFICATE OF DEPOSIT #247412096055702
(INCLUDES ACCRUED INTEREST OF $42.82)
FIRST UNION NATIONAL BANK - CERTIFICATE OF DEPOSIT#247412097048963
(INCLUDES ACCRUED INTEREST OF $30.73)
FIRST UNION NATIONAL BANK - CERTIFICATE OF DEPOSIT #247412097049013
(INCLUDES ACCRUED INTEREST OF $75.68)
VALUE AT DATE
OF DEATH
25,079.11
10,039.58
5,018.41
10,340.83
18,063.17
6,795.45
31,902.88
27,042.82
10,030.73
17,575,68
FIRST UNION NATIONAL BANK - CERTIFICATE OF DEPOSIT #247412097049102
(INCLUDES ACCRUED INTEREST OF $11.19)
BLUE CROSS/BLUE SHIELD - REIMBURSEMENTS
10,011.19
266.85
TOTAL (Also enleron line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
172166.70
~
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
JACOBS LEROY S
FILE NUMBER
21
02
0419
Debls of decedent must be reported on Schedule t
ITEM
NUMBER DESCRIPTION IIMOUNT
II, FUNEAAL EXPENSES:
1- MYERS FUNERAL HOME 90.00
2, GINGRICH MEMORIALS 80.00
B. IIDMINISTAATIVE COSTS:
1- Personal Representative's Commissions
Name of Personal Representati... (s)
Social Security Numbe~s) f EIN Number of Personal Representative(s)
SIJeet IIddress
City State Zip
Y..~s) Commissioo Paid:
2. Attomey Fees BRINSER, WAGNER & ZIMMERMAN 4,000.00
3, Faml~ Exemption: (If decedents address is not the same as claimanls, attach exp"nalion)
Claimant
Street Address
City State Zip
Relalionship of Ctaimantlo Decedent
4. Probate Fees REGISTER OF WILLS 264.00
5. Atoountanfs Fees
6. Tax Return Preparer's Fees
7.
TOTAL (AlSO enter on line 9, Recapitulation) $ 4434.00
(If more space is neeced, insert additional sheets of the same size)
,
"REV.15"""I'.'~.
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
JACOBS LEROY S
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
FILE NUMBER
21 02
0419
Include unreimbulHd medicel expenses.
ITEM
NUM8ER
DESCRIPTION
AMOUNT
1.
VERIZON - PHONE
28.98
2.
BONNEYMEAD FAMILY MEDICINE
100.00
3.
ALBERT PHARMACY
116.90
4.
MESSIAH VILLAGE - BALANCE DUE
2,205.70
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
245158
"",,,,ex""90,*
COMMONWEALTH OF PENNSYLVANIA
INHERiTANCE TAX RETURN
RESIDENT DECEDENT
,
,
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
I 71 n? nA1a
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1 SHARON RUSSELL GRANDDAUGHTER $5,000.00 CASH
1426 N. 6TH STREET, ALTOONA, PA 16601
2. DAVID RUSSELL GRANDSON $5,000.00 CASH
1426 N. 6TH STREET, AL TOONA, PA 16601
3. SCOTT RUSSELL GRANDSON $5,000.00 CASH
1426 S. 6TH STREET, AL TOONA, PA 16601
4. ANGELA JACOBS GRANDDAUGHTER $15,000.00 CASH
725 OBERLIN STREET, STEELTON, PA 17113
5. SHIRLEY ANN RUSSELL DAUGHTER 1/2 RESIDUE
1426 N. 6TH AVENUE, AL TOONA, PA 16601
6. LEROY J. JACOBS SON 1/2 RESIDUE
725 OBERLIN STREET, STEEL TON, PA 17113
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1-
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
,
REV-f5BEX.ll-971,_~_
l' .~
COMMONWEALTH Of PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
'<::crw!,:: 21 n? n.41Q
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributioos)
1. SHARON L.RUSSELL GRANDDAUGHTER $5,000.00 CASH
P.O. BOX 60031, HARRISBURG, PA 17106
2. DAVID A. RUSSELL GRANDSON $5,000.00 CASH
139 E. MAIN STREET, MECHANICSBURG, PA 17055
3. SCOTT L. RUSSELL GRANDSON $5,000.00 CASH
5075 STACEY DRIVE, APT. 201, HARRISBURG, PA 17111
4. ANGELA (JACOBS) LUTZ GRANDDAUGHTER $15,000.00 CASH
725 OBERLIN STREET, STEEL TON, PA 17113
5. SHIRLEY ANN RUSSELL DAUGHTER 1/2 RESIDUE
1426 N. 6TH AVENUE, AL TOONA, PA 16601
6. LEROY J. JACOBS SON 1/2 RESIDUE
725 OBERLIN STREET, STEEL TON, PA 17113
7. ZACHARIAH RUSSELL GREAT-GRANDSON $5,000.00
CIO DAVID A. RUSSELL, 139 E. MAIN STREET
MECHANICSBURG, PA 17055
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17. AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART n - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additiooal sheets of the same Size)
, . .:
WILL
ill:
LEROY S. JACOBS
I, LEROY S. JACOBS, currently of Upper Allen Township, Cumberland County,
. . Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any and all
prior Wills and Codicils made by me.
I. I direct that all my just debts and funeral expenses be paid from the assets of my
estate as soon as practicable after my demise.
II. I direct that all estate and inheritance taxes that may be assessed in consequence of
my death, shall be paid out of the principal of my general estate to the same effect as if said
taxes were expenses of administration and all property includable in my taxable estate
whether or not passing under this Will shall be free and clear thereof.
III. All the rest, residue and remainder of my estate, of whatever nature and wherever
situate, including property over which I hold a power of appointment, I devise and bequeath
as follows:
A. Five Thousand Dollars ($5,000) unto each of my daughter's
children, namely, Sharon, David and Scott.
B.
Angela.
Fifteen Thousand Dollars (15,000) unto my son's daughter,
C. Five Thousand Dollars ($5,000) unto each of my great-
grandchildren who survive me.
D. All the rest, residue and remainder of my estate I devise and
bequeath equally unto my children, Shirley and Leroy. If either child
predeceases me, his or her share shall pass unto his or her issue per stirpes.
If said child leaves no issue, said share shall lapse and be added to the share
passing to my other child or his or her issue per stirpes.
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IV. I appoint my daughter, Shirley Ann Russell, and my son, Leroy J. Jacobs,
Executors, or the survivor of them as sole Executor, of this my Will.
V. I direct that no bond be required of my fiduciaries for the faithful performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I, LEROY S. JACOBS, herewith set my hand to this
my Last Will, typewritten on two (2) sheets of paper including the attestation clause and
signatures of witnesses, this,?,,*, day of .:r v L. " , 2001.
~~~. <h...~SEAL)
. LER S. JAC~
Signed by LEROY S. JACOBS, by him declared to be his Will in our presence, who
have hereunto subscribed our names as witnesses in his presence and at his request, this
;t '{.,... ~ of Tc.) i.. 'I ,2001.
~,(~ residing at d~ ~..A
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residing at
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF T
JIISlq C.u.'M.bQr\0.4..
WE, LEROY S.JACOBS, GERALD J. BRINSER and 13ot.r'y<...o! /5f'QO"'~
the testator and the witnesses, respectively, whose names are signed to the attached or
foregoing instnlment, being first duly affirmed, do hereby declare to the undersigned
authority that the testator signed and executed the instnlment as his Last Will and that he
signed willingly (or willingly directed another to sign for him), and that he executed it as his
free and voluntary act for the purposes therein expressed, and that each of the witnesses, in
the presence and hearing of the testator, signed the Will as witnesses and that to the best of
our knowledge the testator was at thattime eighteen years of age or older, of sound mind and
under no constraint or undue influence.
.
(
lNESS
Wl~~~-r- ~Jl'''.~''4~
Subscribed, sworn or affirmed and acknowledged before me by LEROY S. JACOBS, the
testator, GERALD J. BRINSER and i?>e:\t."Iy~ B~(J.>.:>s c..:r , witnesses, this
~'Iti. day of ..:r U.1 ,2001.
~)n. ~ (SEAL) ...:
~ Notary Public
_8e8I
\/Icky M. _1IolaJy Public
Upper AIIon Twp., CUmbelfond CounIy
My Cu....lisIloI. ExpIres Dee. 31, 2001
Member, Pennsylvlnla AssocIaUcn 01 NotaJ1es
"
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MARY C. LEWIS, REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
;;?
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: LEROY $. JACOBS
Date of Death: 4/22/02
Estate No. 2002-Q0419
SSN: 057-10-4212
File No. 21-Q2-Q419
Date Letters Granted: 4/25/02
Will or Administration No.
To the Register:
I certify that Notice of Estate Administration required by Rule 5.6(a) of the Orphans' Court Rules was served
on or mailed to the following beneficiaries of the above-captioned estate on JUNE :3. 2002.
Name Address
ANGELA JACOBS 725 OBERLIN STREET
STEEL TQ~:L_____.. _ PA 17113
SHARON L. RUSSELL P.O. BOX 60031
H~BHIS6URG__________ PA 171QE3
SCOTT L. RUSSELL 5075 STACEY DRIVE, APT. 201
H~BBJ~BURG PA 17111
DAVID A. RUSSELL 139 E. MAIN STREET
ME(:::I-lA~IQSBUB~ PA 17()55
ZACHARIAH RUSSELL 139 E. MAIN STREET
C/O DAVID A. RUSSELL MECHANICSl3lJRG. PA 17055
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
SHIRLEY ANN RlJ~~ELL AND LEROY 4. 4A.gQI3~,J:;.Q-I::>SECUTORS. WHO MET IN OUR OFFICE.
Personal Representative
X Counsel for Personal
Representative
~? ~.I..!Ltk-
Signature
GEBALD J.BFilN.s.ERESQWRI;
Name (Please type or print)
~E~ M~NSIBEET
Address
P.Q. BQ)(~2:3
Date: 6/3/02
Capacity:
PAl.. MYRA
PA 17078
c....J
Telephone No. (717)838-6348
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~ BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
'*
REV-ln7 EX AFP lDl-D2l
GERALD J BRINSER
6 E MAIN ST
PO BOX 323
PALMYRA
ESQ
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
12-03-2002
JACOBS
04-22-2002
21 02-0419
CUMBERLAND
101
LEROY
S
Allount Rellitted
PA 1'7078
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV=i60-j-i3f-AFP--foY:02Y------...-iNi.fERITANc'E--TA3f-si'jrfEM'E-NT-ifF-Aircouiff--.-i.---------------- -----
ESTATE OF JACOBS LEROY S FILE NO. 21 02-0419 ACN 101 DATE 12-03-2002
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 11-19-2002
PR I NCI PAL TAX DUE: .................................................................................................................................................................................
..........................................
8,304.97
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
07-15-2002 CDOO1408 382.45 7,266.63
10-22-2002 CDOO1765 .00 655.89
TOTAL TAX CREDIT 8,304.97
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
. IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1,
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ,
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J
'\. /7-S1-0
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
GERALD J BRINSER
6 E MAIN ST
PO BOX 323
PALMYRA
DATE
ESTATE OF
DATE OF DEATH
I;ILE NUMBER
t:oUNTY
ACN
11-19-2002
JACOBS
04-22-2002
21 02-0419
CUMBERLAND
101
ESQ
*'
REY-15~7 EX AFP [Ol-OZl
LEROY
S
Allount Rellitted
PA 17078>.
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV =iS4j-E3f-Ai=p-(oY=o2T-No'~fICE--oF-YNHEifI;:ANCE-TAi-A-pPRAIsEifiNT-:--AL1-owANcE-'(fi-------------- ---
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF JACOBS LEROY S FILE NO. 21 02-0419 ACN 101 DATE 11-19-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ~ returns assessed to date.
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 = .00
184,554.92 X 045 = 8,304.97
.00 X 12 = .00
.00 X 15 = .00
(19)= 8,304.97
RESERVA7ION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
4. Hortgages/Notes Receivable (Schedule D) (4)
5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
NO. 01
.00
.00
.00
.00
.00
.00
14.590.33
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) (9)
10. Debts/Hortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
15.00
.00
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
14,590.33
15 00
14,575.33
.00
184,554.92
n.. ..."".. I II:C\.C.LI'" I (+J AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
07-15-2002 CDOO1408 382.45 7,266.63
PAYMENT MUST BE MADE BY 01-22-2003~. TOTAL TAX CREDIT 7,649.08
BALANCE OF TAX DUE 655.89
INTEREST AND PEN. .00
TOTAL DUE 655.89
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A ..CREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
1-'/ -'~-1-;Z.5
~ BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
*'
REV-liD7 EX iFP 101-021
GERALD J BRINSER
BRINSER ETAL
PO BOX 323
PALMYRA
ESQ
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
08-26-2002
JACOBS
04-22-2002
21 02-0419
CUMBERLAND
101
LEROY
S
Allount Rellitted
PA 17078
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV =i6cfj-E3f-iF'P--('oY:02Y------...--iNifiRITANCE--fAx-sTA-yEME-rif-cfF'-Ac-couiiy--.-i.------------------ ---
ESTATE OF JACOBS LEROY S FILE NO. 21 02-0419 ACN 101 DATE 08-26-2002
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 08-12-2002
P R I NCI PAL TAX DU E : ..............................................................................................................................................................................
.............................................
7,649.08
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
07-15-2002 CDoo1408 382.45 7,266.63
TOTAL TAX CREDIT 7,649.08
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
II
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1,
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ,
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J
/? -.c9 - 'X.!5
" BUREAU OF INDIVIDUAL TAXES
~ INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
08-12-2002
JACOBS
04-22-2002
21 02-0419
CUMBERLAND
101
GERALD J BRINSER
BRINSER ETAL
PO BOX 323
PALMYRA
ill
. .
ESQ
PA(.17078
'*
REY-1547 EX AFP [01-021
LEROY
S
Anount Renitted
) CHANGED
U)
(2)
(3)
(4)
(5)
(6)
(7)
.00
4,698.47
.00
.00
172,166.70
.00
.00
(8)
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV =iS4f-E3f-AFP-CoY=02Y-NcfficE--oF-YNHEifiTANcE-'fA'irAPPRA-isEi'-ENT~--Ar:rOWAirCE-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF JACOBS LEROY S FILE NO. 21 02-0419 ACN 101 DATE 08-12-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adn. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governnental Bequestsj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
UO)
4,434.00
NOTE: To insure proper
credit to your account,
subnit the upper portion
of this forn with your
tax paynent.
176,865.17
6.885 58
169,979.59
.00
169,979.59
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Anount of Line 14 at Spousal rate (15)
16. Anount of Line 14 taxable at Lineal/Class A rate (16)
17. Anount of Line 14 at Sibling rate (17)
18. Anount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 = .00
169,979.59 X 045 = 7,649.08
.00 X 12 = .00
.00 X 15 = .00
(9)= 7,649.08
2.451.58
Ul)
(2)
(3)
(4)
. ~...~n. n~_~.. l+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
PAYMENT MUST BE MADE BY 01-22-2003*. TOTAL TAX CREDIT .00
BALANCE OF TAX DUE 7,649.08
INTEREST AND PEN. .00
TOTAL DUE 7,649.08
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
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COMMONwEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 1712SOOl1
REV.1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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IlECEDEIml NAIoE (lAST. FIRST, AND IoID1lLE 11tT1AL)
JACOBS LEROY S.
OI\TE OFllEATH (I&l.oo.Vea1
OI\TE OF BIRTH (!AWD-Vea1
OFFIClH.USEOIt..Y
....---
04J2212002 10/19/1915
OF APPlJCAIllE) SURVMNG SPOUSE'S NAME (lAST, FiRST, AND M1DOlE INIT1Al)
N/A
o 1. Orillnal Return
o 4. Linited Estall!
o 6.DecedentOIedTestaIe__,,\YI)
o 9. Litigation Proceeds Received
00 2. SUpplerrental Return
o 4a.FullJn>inlBISSlCompmn;seC.."_....'2.'2.a2)
o 7. Decedent Mainll!lned a LiYIng TRlSt _",,"Trull)
o 10.SpoosalPovertyCred~I.."__,.31-9'..'.'-951
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FILE HUIIBER
2 1 -0 2 0 4 1 9
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SOCIAl SECURITY NUMBER
057-10-4212
TIIS REIIlRM IIJST BE FI.ED II OOPUCATE WIIH THE
REGISTER OF WILLS
SOCIAl SECURITY NUMBER
o 3. RemainderRaflJrn (4fIIo"_....b'.'3.a2)
o 5. Federal EstaIll Tax Relurn Raquked
_ 8. Total Nu_olSafe Deposil Boxes
o 11.E1ecIion 10 lax under See. 9113(A) -. Sell 0)
'IlllS seCTION "LIST BECOIIIPLETl!D.'ALl.CORREsPONDENcEAND FIDE TAX INFORMATION SHOULD BE TO:
!i NAME COMPLETE MAILING ADDRESS
I GERALD J. BRINSER ESQUIRE 6 E. MAIN STREET
FIRMNAME (IfAjJpicallfeJ
BRINSER WAGNER & ZIMMERMAN P.O. BOX 323
o TELEPHONE NUMBER
u 717 838~348 PALMYRA PA 17078
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1. RealEstall! (Schedule A) (1)
2. _ and Bonds (Schedule B) (2)
3, Closely Held~. Par1netsh/p or~roprietorship (3)
4, ~ages & Noles RaceiYablo (Schedule 0) (4)
5. Cash. Bank Depos/ts & Miaca.a"eous Per.IortaI Properly (5)
(Schedule E)
6, JoInlIy Owned Pmparly (Sdladule F) (6)
o SaparataBiIIng Raques\lld
7, _,VIVOS Transfets & MIscalaneous Non-Probala Pmparly (7)
(Schedule G or L)
8, ToIIlG...._(1otallines 1.7)
9, Funeral Expanses & Adnlnistrative Cos1!l (Schedule H) (9)
10. DabIs olllac:edant. Mortgage liabilities, & Liens (Schedule I) (10)
11. T....Doductions(1otaILlnes9& 10)
12, NolValueofEolaflt (lIIa 6n1nus Line 11)
13, Charilablaand eo.emmantal BaQueslsISec9113 Trusts for which an _10 lax has nol been
made (Schedule J)
14, NolValue Subjeclto TIl (line 12 minus line 13)
SEE INSTRUCTIONS ON REVERSE SIlE fORAPPUCABLE RATES
15. Amount ol Une 14 taxable at II1a 8/JOUSll11ax
raIll, ortransfets under Sac, 9116 (aX1.2)
16. Amount of Line 14_ aI inaal....
1T.AmountofLina 14 faxableat~raIll
18,AmountolUne 14 _at_rata
19. TIl Duo
0.00 X
14.575,33 X
0,00 X
0.00 X
20.0
CHECK YERE f 'CU ARE REQUESTI% ^ REFUI,D 0' All CI/E,PA.I,IE'H
'OI'FICIAL USE ONL V
14,590,33
15.00
14.575,33
14,575,33
655,89
655,89
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CITY
STATE PA
ZIP 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2. CreditslPayments
A. Spousal PoV9lty Credit
B. Prior Payments
C. Discount
(1)
655.89
TolaICredits(A+B+C) (2)
3. Interes1lPenalty ~ applicable
O.In\ereSl
E. Penalty
Tolallnteres1lPenalty ( 0 + E )
4. K Une 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 \0 reqUMla mund
5. K Line 1 .. Line 3 is greater lhan Line 2, enler lhe difference. This is the TAX DUE.
(3)
(4)
(5)
(SA)
(5B)
10: REGISTER OF WILLS, AGENT
655.89
A. Enter lhe interest on !he tax due.
B. Enter the total 01 Line 5 + SA. This is the BALANCE DUE.
Make
655.89
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN .X.'N THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. IllIain \he use or income of the property transferred; ........................................................................... 0 00
b. retain the right to desJgnalewho shall use the propertytranslerred or its income: ........................................ 0 00
c. retain a reversionary interest; or ...................................................................................................... 0 00
d. receive the promise for Iile 01 eilher payments, beneflls or care? ............................................................. 0 00
2. If deaJh occurred after December 12, 1982, did decedent transfer property within one year 01 death
without receiving adeql.Jate Consideration?............................................................................................... 0 00
3. Did decedent own an 'in trust for' or payable upon dealh bank account or securily at his or her death? ................. 0 00
4. Did decedent own an Individual Retirement Account, annuity, 0( other non-probate property which
contains a beneficiary designation? ....................................................................................................... 00 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under~dperjury.l_ ~al r __ ~is roIum. includ;~'!"""'!""yingschedu..and_la,and ~lhebootdlll'll<ooo\edgeandbellel.~islnle, ","""and~.
Dec:ImIIond JI'IIl8lW otJertha\!he personal IeplesentaIive Is based on a11l1bm1lion dwhic:f1 preplI8I' '- 8'ly krIcJwIedge.
S~~~RE JN~FORFrLINGRETURN DATE .
_ _ _Z41'#/'-e:-' - 13y-t"r' /fI/-<.//tlJ
ESS IN STREET
STEELTON PA 17113
SIGNATUREOFPREP~~OTHERTHANRE~PRES ATiVE _ DATE
22.iZ,i-df( _1....~....., /0,17- 0 L
AllDRESS 6 E. MAIN STREET, .0. BOX 323
PALMYRA PA 17078
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FOI dates 01 deah on 0( after July 1, 1994 and before JanuaIY 1, 1995. the tax rate imposed on lhe net value 01 transfers to 0( for !he use 01 the surviving spouse is 3%
[72 P.S. 59116 (a) (1.1) (il).
FOIdates oIdealh on or after JanuaIY 1, 1995,the tax rate imposed on the net value 01 transfers to O(for the use 01 !he surviving spouse is 0% [72 P.S. 59116 (a) (1.1) (i)].
The statute does not exernDl a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of asseIS and filing a tax return are stiil applicable even ~
the surviving spouse is the only beneficiary.
For dales 01 death on 01 after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child lwenty-ooe yeas 01 age or younger at dealh to or for the use of a natural parent, an adoptive parent,
0( a stepparent of the child is 0% [72 P.S. S9116(a)(1.2lJ.
The tax rate imposed on the net value oItransfen; to or for !he use 01 the decedent's lineal beneficlarles Is 4.5%, except as noted in 72 P.S. S9116(1.2) [72 P.S. 59116(a)(1)).
The tax rate Imposed on !he net value 01 transfers to or fO( the use of the decedenfs siblings is 12% [72 P.S. 59116(a)(1.3)). A sibling is defined, under Section 9102, as an
Indvidual who has a11eas\ one parent In common wilIl\he decedent, whether by blood or adoption.
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~TH OF PEItlSYlVAIIA
INHERITANCE TAX RETURH
RESIDENT DECEDENT
ESTATE OF
JACOBS LEROY S
SCHEDULE G
INTER.VlVOS TRANSFERS &
MISC. NON.PROBATE PROPERTY
FILE NUMBER
21 02
0419
Tl1ls schedule _ be compIolod and lied rlhe _to any of questions 1lhrough 4llfllhe I8'IeIS8 side ollhe REV-1500 COVER SHEET Is yea.
DESCRIPTION OF PROPERTY %OF
ITEM IItCUllETttEPWEOFMTlWtIFEAEE, THElRRElA1JCIillltW'TOlECeDENT ftHIJnEMlEOFTIWIIfBl DATE OF DEATli oeclYS eXCLUSION TAXABlE VALue
NUMBER AnACHACt7tOFnE DEEDFORAEAL ESTATE. VALue OF ASSET INTEReST """""""
1. ING RELlASTAR - FLEXIBLElNON-QUALlFIED ANNUITY - 14,590.33 100. 14,590.33
#SFUA001801, WITH CHILDREN, LEROY J. JACOBS AND
SHIRLEY A. RUSSELL, NAMED AS BENEFICIARIES.
TOTAL (Also enter on line 7, RecaPtuJatlon) S 14590.33
(R more space Is needed, Insert adcItIonal sheets 01 the sane size)
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October 16. 2002
VIA FACSIMILE
AttD: Gerald Brinser
Re: Leroy S. Jacobs, deceased
ReliaStar Life Insurance Company
Annuity Contract Number: SFUAOOl801
Dear Sir or Madam:
At your request the accumulated value of the above-mentioned Contract as of the date of
Leroy Jacobs' passing, April 22, 2002 was 514,590.33.
If you have any questions, please do nol hesitale to contact our Claims Deparunent at
1-877-884-5050 between thc hours of8:00 a.m. and 5:00 p.m. CST.
Sincerely,
MdK&trJ &rrJrnil
Mandy J. Burckhard,
Customer Service Representative
Claims Department
P.O. Box 5050
Minot, NO 58102-5050
'foil Free: 811.884.5050
R.eliaSrar Life Insur:mce Company
nY: 888.222.1735
servlcecenteJ'@us.ing.com
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COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
JACOBS LEROY S
DeblII of decedent mull be reported on Schedule I.
FILE NUMBER
21 02
0419
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Persooal Representatlve's Conunissions
Name of P""""",I Representative (s)
SocIal Security Number(s) I EIN Number of PeIsonaI ~,taIive(s)
S1reeI Address
City Slala Zip
Yea~s) ~ Paid: .
2. AIlomey Fees
3. F aml~ Exampllon: (U decedanfs address Is not the same as claimant.. aIIach explanation)
Claimant
SInleI Address
City State Zip
.
Relationship 01 Claimant to Decedent
4. Probate Fees
5. Acoounlanfs Faes
6. Tax Retum P_.... Faes
7. REGISTER OF WILLS - SUPPLEMENTAL FILING FEE . 15.00
TOTAL (Also enter on line 9, Recapitulalion) $ 15.00
(K more space is needed, insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETlJIlN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
I CDf"IV!,: .,1 Ii., /lA11l
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIV1NG PROPERTY Do Not list Trullet(l) OF ESTATE
I. TAXABLE DISTRIBUTIONS (Include outJi!Ilt spousal distributions)
1. SHARON L.RUSSELL GRANDDAUGHTER $5,000.00 CASH
P.O. BOX 60031, HARRISBURG, PA 17106
2. DAVID A. RUSSELL GRANDSON $5,000.00 CASH
139 E. MAIN STREET, MECHANICSBURG, PA 17055
3. SCOTT L. RUSSELL GRANDSON $5,000.00 CASH
5075 STACEY DRIVE, APT. 201, HARRISBURG, PA 17111
4. ANGELA (JACOBS) LUTZ GRANDDAUGHTER $15,000.00 CASH
725 OBERLIN STREET, STEELTON, PA 17113
5. SHIRLEY ANN RUSSELL DAUGHTER 112 RESIDUE
1426 N. 6TH AVENUE, AL TOONA, PA 16601
6. LEROY J. JACOBS SON 1/2 RESIDUE
725 OBERLIN STREET, STEELTON, PA 17113
7. ZACHARIAH RUSSELL GREAT-GRANDSON $5,000.00
C/O DAVID A. RUSSELL, 139 E. MAIN STREET
MECHANICSBURG, PA 17055
ENTER 00LlAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET S
(" more space Is needed, Insert addtional sheets of the sane SIZe)
WILL
QE
LEROY S. JACOBS
I, LEROY S. JACOBS, currently of Upper Allen Township, Cumberland County,
. Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any and all
prior Wills and Codicils made by me.
I. I direct that all my just debts and funeral expenses be paid from the assets of my
estate as soon as practicable af1:er my demise.
II. I direct that all estate and inheritance taxes that may be assessed in consequence of
my death, shall be paid out of the principal of my general estate to the same effect as if said
taxes were expenses of administration and all property includable in my taxable estate
whether or not passing under this Will shall be free and clear thereof.
III. All the rest, residue and remainder of my estate, of whatever nature and wherever
situate, including property over which I hold a power of appointment, I devise and bequeath
as follows:
A. Five Thousand Dollars ($5,000) unto each of my daughter's
children, namely, Sharon, David and Scott.
B.
Angela.
Fifteen Thousand Dollars (15,l>OO) unto my son's daughter,
C. Five Thousand Dollars ($5,000) unto each of my great-
grandchildren who survive me.
D. All the rest, residue and remainder of my estate I devise and
bequeath equally unto my children, Shirley and Leroy. If either child
predeceases me, his or her share shall pass unto his or her issue per stirpes.
If said child leaves no issue, said share shall lapse and be added to the share
passing to my other child or his or her issue per stirpes.
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IV. I appoint my daughter, Shirley Ann Russell, and my son, Leroy J. Jacobs,
Executors, or the survivor of them as sole Executor, of this my Will.
V. I direct that no bond be required of my fiduciaries for the faithful performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I, LEROY S. JACOBS, herewith set my hand to this
my Last Will, typewritten on two (2) sheets of paper including the attestation clause and
signatures of witnesses, this.,.?~ day of .:TVL)I ,2001.
~~- ~~ <2z....~SEAL)
. LER S. JAC~
Signed by LEROY S. JACOBS, by him declared to be his Will in our presence, who
have hereunto subscribed our names as witnesses in his presence and at his request, this
~ y't>\ {!f of .:r" i..1 ; 20~ 1.
~~ ~ IJA _ residing at ~ ~..12
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COMMONWEALTH OF PENNSYLVANIA
lUM tu.'Mb(>...\~
COUNTY OF T
WE, LEROY S.JACOBS, GERALD J. BRINSER and f3ot.....'f<...~ 6f'QOv.ls"'f
the testator and the witnesses, respectively, whose names are signed to the attached or
foregoing instrument, being fIrst duly affrrrned, do hereby declare to the undersigned
authority that the testator signed and executed the instrument as his Last Will and that he
signed willingly (or willingly directed another to sign for him), and that he executed it as his
free and voluntary act for the purposes therein expressed, and that each of the witnesses, in
the presence and hearing of the. testator, signed the Will as witnesses and that to the best of
our knowledge the testator was at that time eighteen years of age or older, of sound mind and
under no constraint or undue influence.
,
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Subscribed, sworn or affirmed and acknowledged before me by LEROY S. JACOBS, the
testator, GERALD J. BRINSER and ~e:n.."-Jy<& Bpw(l.>:\s r:% , witnesses, this
~'Iti. day of .:r lA.'1 ,2001.
0'?n. ~ (SEAL) "
Notary Public
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VIcky M. ........ N*Jy N>lIc
lJIlpof _Twp.. c...._ CoIo1ly
My CO...4aIIon &pires Dec. 31. 2001
Member. ~~ 01 NoIar1es
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